Subtrochanteric Femur Fracture. 70 yo female 7/22/2013

Transcription

1 Subtrochanteric Femur Fracture Philip J. Kregor, MD 70 yo female Mild hypertension, Type II Diabetes Fell from 20 feet while at a party when the porch collapsed Mild head injury, Rib fractures Had been told she had Osteopenia based on BMD test, but no medical treatment 1

2 Goals of Treatment Fracture Union Re-establishment of normal neck-shaft angle and femoral anteversion Minimal disruption of the abductors Ability to mobilize and weight bear Options IM Nail Piriformis Starting Point Greater Trochanteric Starting Point 95 degree Plate Fixation 2

3 3 months post-injury 4 months post-injury Thoughts? No past history of infection WBC, ESR, CRP normal Worked up by Bone Endocrinologist no Ca or Vitamin D issue 3

4 Nonunion / Complication Get the original xrays, OP note, and as many follow-up films as possible Ask if there is a history of infection Ask about metabolic problems (Diabetes, Cigarette Smoking, Vitamin D) Consider Ca and Vit D work-up ESR, CRP Talk to previous surgeon if possible Share xrays / Ask opinions OPTIONS FOR SURGICAL TREATMENT? Repeat IM Nailing Plate Fixation Other? Questions How do get out the nail? How do you correct the deformity? Does the fracture need to be compressed? Is there any rotational deformity which should be corrected? Does it need a bone graft? 4

5 Removal of Broken Nail without opening up the fracture and destroying the Biology.What Bob Winquist taught us all. 1. Remove the set screw in the nail 2. Remove the compression screw 3. Remove the proximal end of nail 4. Correct the deformity 5. Have a replica of the nail on the back table 6. Utilize a combination of a bulb tipped guide wire and straight guide wire to jam in the end of the nail 7. Extract the nail 5

6 1 Month Post-Operative 2 Months Post-Operative 6

7 THANK YOU Philip J. Kregor, MD 7

8 Tibial Nonunions Aaron M. Perdue, M.D. University of Michigan 52 y/o M Fell feet off cliff into river Rescued 6 hours after injury (still in river) PMHx: HTN 1

9 Goals of Treatment Initiation of antibiotics 1. Ancef 2. Ancef + Gent 3. Ancef + Gent + PCN 4. Something + Vanco 5. Other Goals of Treatment Initial Debridement 1. < 6 hrs hrs hrs 4. > 24 hrs Goals of Treatment Initial Surgical Intervention (I&D a given) 1. External fixation 2. Intramedullary nailing 3. Plating 4. Splint 2

10 Goals of Treatment Initial Dead Space/Wound Management 1. Sterile dressing 2. Wound vac 3. Antibiotic beads 4. Antibiotic spacer 5. Antibiotic beads/spacer + Wound vac Goals of Treatment Repeat debridements 1. No, definitive fixation day # First case 7:30 a.m. 3

11 Hospital Day #2 Hospital Day #3 Coverage 4

12 Goals of Treatment Bone defect management? 1. Immediate allograft with BMP 2. Immediate autograft 3. Antibiotic spacer with delayed allograft with BMP 4. Antibiotic spacer with delayed autograft Post op day #68 Post op day #85 Infection treated with debridement, antibiotic spacer, and antibiotics 5

13 Options? Antibiotics completed and labs normal 6 months from injury: 1. Allograft with BMP 2. AICBG 3. PICBG 4. RIA 5. A bone graft + revision nailing 6. A bone graft + revision ORIF Ipsilateral femur RIA 6 weeks / 12 weeks 6

14 Damage Control Plating (DCO) Damage Control Plating (DCO) 7

15 Questions? 8

16 Trauma Complications Webinar: Clavicle Fractures Peter A. Cole MD Professor- University of Minnesota Chief- Regions Hospital 37 Y.O. Female 8 years status post ORIF diaphyseal clavicle nonunion Chief Complaint: Pain, cosmesis, function Pertinent Hx: 1 ppd smoker IV Drug Use Prostitute Rx Abuse Revision ORIF recommended, however, patient had difficulty with follow up 3 years later 1

17 4 years later Surgical Strategy Staged: 1. HWR w/ I&D and cultures 2. ORIF w/ ICBG Stage 1- culture negative 2

18 18 months later 3

19 4

20 Day 0 Post Op 5

21 2 months Post Op 1 Year Post Op Clinically with near full range of motion and no pain. 6

22 Failed Femur Fractures Bradley Dart MD Failed Femur Fractures 62 y/o Male Fractured Femur 4 years ago in MVC Works in office setting Ambulates with Crutch Hypertension 1

23 Strategy? Strategy for Developing a Good Treatment Plan Fracture History Nonunion Features Metabolic Status Injury 4 yrs prior 2

24 Initial Treatment Predictions? Attempt # 2 3

25 Current Status 4 yrs Post Injury Current Status 4 yrs Post Injury Pt complaints: Pain Short Leg (4cm) Unstable Treatment Plan? 4

26 Additional Information CT Scan?? Metabolic Labs?? Additional Information CT Scan?? Metabolic Labs (CBC, CMP, Vit D, PTH, Testosterone) Vit D level of 19 Others normal Principles? 5

27 Principles Stability Compression Biology Surgical Plan? Surgical Plan Blade Plate Post Iliac Crest Graft Excise dead or unhealthy bone Restore Length / Rotation Sacrifice Compression for Length 6

28 Intra Op Tools Blade plate Opposite femur Mechanical alignment Femoral Distracter Articulated clamps Articulated Compression Device 7

29 Final Result Questions 8